Provider Demographics
NPI:1902562291
Name:WALIA, GURSIMRAN SINGH
Entity Type:Individual
Prefix:
First Name:GURSIMRAN
Middle Name:SINGH
Last Name:WALIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33209 GREAT SALT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-1209
Mailing Address - Country:US
Mailing Address - Phone:510-648-5936
Mailing Address - Fax:
Practice Address - Street 1:1801 W 11TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3727
Practice Address - Country:US
Practice Address - Phone:209-830-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist